MYPlogo | Mind Your Performance
Book Now

New Client Intake Forms

General Information

You and your child are being asked to provide consent and assent to Camryn Weller to apply her knowledge of sport mental performance enhancement in consultation and provide services that entail the following:

  1. Provide evidence-based information related to the performance and psychology within sport and exercise to physically active individuals, groups, and/or organizations.
  2. Educate individuals on performance enhancement techniques or mental skills (goal-setting, concentration, self-talk, imagery) to improve performance-related concerns (motivation, confidence, performance anxiety, arousal control, injury rehabilitation).
  3. Assist and support athletes or physically active individuals in the mental journey within their sport or exercise to positively impact their overall sport performance.

Please note: The objective of Mental Performance Consultants is to provide a service to their clients to maximize their mental skills in order to achieve optimal sport performance. Mental Performance Consultants are not qualified to diagnose or counsel individuals with mental illnesses, eating disorders, and/or other concerns related to clinical counseling. If an athlete presents a concern that is beyond my scope of practice at any time in our sessions with one another, based on their specific needs I may refer them to their school counselor or be contacting the guardian and refer this athlete to a qualified specialist that is better suited to address their specific needs.

Voluntary Consent

  1. Obtaining mental performance consultation from Camryn Weller is entirely voluntary. With this being said, the client has the right to terminate their sessions or participation in any sessions at any time, with no further explanation to the consultant. This removal from participation can be temporary (such as in group sessions or individual sessions for the day), or can be a permanent decision based upon the client or guardian.

Confidentiality

  1. All personal matters or personally-identifiable information discussed with the client in group or individual sessions are to remain confidential between the client and consultant. There are specific exceptions in which a breach of confidentiality may transpire:
    1. Written permission from the client and guardian
    2. There is a suspicion of abuse or neglect to be transpiring within any vulnerable population (child, elderly, individuals with a disability)
    3. The client is of imminent danger to themselves
    4. The client is of imminent threat to others

As a mandated reporter, I am required by law to report any incidents involving child abuse or maltreatment. The Summary Guide of Mandated Reporters In New York State is provided in this document from https://ocfs.ny.gov/publications/Pub1159/OCFS-Pub1159.pdf. Please refer to the bottom left section of the first page in this summary to learn more information about specific information that I am required by law to mandate.

  1. Parental Access
    Parents or legal guardians have the right to access client or session records regarding their child at any time. With this being said, it is highly requested that parents/legal guardians trust the Mental Performance Consultant that they will notify the adult of any situations that raise serious concern for the minor’s well-being as quickly as they can when or if the situation ever arises. If the Mental Performance Consultant does contact or notify the parent/legal guardian, they will attempt to notify the client of this conversation beforehand, if possible.
  2. Group sessions
    It is not guaranteed that any and all personal information that is shared within a group setting will not be shared by the other teammates or children outside of sessions. Although it will be highly requested by the Mental Performance Consultant before each session to not share other individual’s information and that whatever information is shared within the group should stay within the group, the child can remove themselves from a group session at any time they feel comfortable doing so, as well as determine for themselves what information they feel comfortable sharing in front of others. If an individual is more comfortable to share such information later in an individual session with only the Mental Performance Consultant, they are free to do so.

 

Session Fees

  1. Payment for all mental performance sessions is due prior to the session at the time of booking. Payments are processed securely through Square, and can be made using a credit or debit card.
  2. The consultant will discuss, if not already reviewed, the available session package options as well as individual session rates prior to your first session or at your request. Please ensure you understand and agree to the selected rate before proceeding with booking.

Failure to provide payment prior to a scheduled session may result in the session being rescheduled or canceled.

Use of Technology

A. For educational and marketing purposes, portions of group session activities or materials may be recorded and shared on professional social media platforms (e.g., @mindyourperformancempc). These posts will never disclose personal or sensitive information.

C. Communication regarding session content or scheduling may take place via email at camryn@mindyourperformance.net. In addition, your child may be provided with my phone number to be used exclusively for session-related matters. All communication will remain appropriate and within professional boundaries.

By signing below, I acknowledge that I have read and understood the information provided to me in this document regarding the services that will be provided to me or my child, the confidentiality procedure within this line of work, session fees, and use of technology.

Clear Signature
MM slash DD slash YYYY
Clear Signature
MM slash DD slash YYYY

General Information

You are being asked to provide consent to Camryn Weller to apply her knowledge of mental performance enhancement in consultation and provide services that entail the following:

  1. Provide evidence-based information related to performance psychology for individuals, groups, and/or organizations engaged in high-performance, goal-driven, or personally meaningful activities.
  2. Educate individuals on performance enhancement techniques or mental skills (goal-setting, self-talk, emotional regulation, stress management) to improve performance-related concerns (motivation, confidence, decision-making, imposter syndrome, life balance, burnout prevention).
  3. Assist and support individuals in their personal or professional performance journey to positively impact their overall growth, wellbeing, and effectiveness in their chosen performance environment.

Please note: The objective of Mental Performance Consultants is to provide a service to their clients to maximize their mental skills in order to achieve optimal sport performance. Mental Performance Consultants are not qualified to diagnose or counsel individuals with mental illnesses, eating disorders, and/or other concerns related to clinical counseling. If an athlete presents a concern that is beyond my scope of practice at any time in our sessions with one another, based on their specific needs I may refer them to their school counselor or be contacting the guardian and refer this athlete to a qualified specialist that is better suited to address their specific needs.

Voluntary Consent

  1. Obtaining mental performance consultation from Camryn Weller is entirely voluntary. With this being said, the client has the right to terminate their sessions or participation in any sessions at any time, with no further explanation to the consultant. This removal from participation can be temporary (such as in group sessions or individual sessions for the day), or can be a permanent decision based upon the client or guardian.

Confidentiality

  1. All personal matters or personally-identifiable information discussed with the client in group or individual sessions are to remain confidential between the client and consultant. There are specific exceptions in which a breach of confidentiality may transpire:
    1. Written permission from the client and guardian
    2. There is a suspicion of abuse or neglect to be transpiring within any vulnerable population (child, elderly, individuals with a disability)
    3. The client is of imminent danger to themselves
    4. The client is of imminent threat to others

As a mandated reporter, I am required by law to report any incidents involving child abuse or maltreatment. The Summary Guide of Mandated Reporters In New York State is provided in this document from https://ocfs.ny.gov/publications/Pub1159/OCFS-Pub1159.pdf. Please refer to the bottom left section of the first page in this summary to learn more information about specific information that I am required by law to mandate.

  1. Group sessions
    It is not guaranteed that any and all personal information that is shared within a group setting will not be shared by the other teammates outside of sessions. Although it will be highly requested by the Mental Performance Consultant before each session to not share other individual’s information and that whatever information is shared within the group should stay within the group, the individual can remove themselves from a group session at any time they feel comfortable doing so, as well as determine for themselves what information they feel comfortable sharing in front of others. If an individual is more comfortable to share such information later in an individual session with only the Mental Performance Consultant, they are free to do so.

Session Fees

  1. Payment for all mental performance sessions is due prior to the session at the time of booking. Payments are processed securely through Square, and can be made using a credit or debit card.
  2. The consultant will discuss, if not already reviewed, the available session package options as well as individual session rates prior to your first session or at your request. Please ensure you understand and agree to the selected rate before proceeding with booking.
  3. Failure to provide payment prior to a scheduled session may result in the session being rescheduled or canceled.

Use of Technology

A. For educational and marketing purposes, portions of group session activities or materials may be recorded and shared on professional social media platforms (e.g., @mindyourperformancempc). These posts will never disclose personal or sensitive information.

C. Communication regarding session content or scheduling may take place via email at camryn@mindyourperformance.net. In addition, you may be provided with my phone number to be used exclusively for session-related matters. All communication will remain appropriate and within professional boundaries.

By signing below, I acknowledge that I have read and understood the information provided to me in this document regarding the services that will be provided to me, the confidentiality procedure within this line of work, session fees, and use of technology.

Clear Signature
MM slash DD slash YYYY

General Information

You are being asked to provide consent to Camryn Weller to apply her knowledge of sport mental performance enhancement in consultation and provide services that entail the following:

  1. Provide evidence-based information related to the performance and psychology within sport and exercise to physically active individuals, groups, and/or organizations.
  2. Educate individuals on performance enhancement techniques or mental skills (goal-setting, concentration, self-talk, imagery) to improve performance-related concerns (motivation, confidence, performance anxiety, arousal control, injury rehabilitation).
  3. Assist and support athletes or physically active individuals in the mental journey within their sport or exercise to positively impact their overall sport performance.

Please note: The objective of Mental Performance Consultants is to provide a service to their clients to maximize their mental skills in order to achieve optimal sport performance. Mental Performance Consultants are not qualified to diagnose or counsel individuals with mental illnesses, eating disorders, and/or other concerns related to clinical counseling. If an athlete presents a concern that is beyond my scope of practice at any time in our sessions with one another, based on their specific needs I may refer them to their school counselor or be contacting the guardian and refer this athlete to a qualified specialist that is better suited to address their specific needs.

Voluntary Consent

  1. Obtaining mental performance consultation from Camryn Weller is entirely voluntary. With this being said, the client has the right to terminate their sessions or participation in any sessions at any time, with no further explanation to the consultant. This removal from participation can be temporary (such as in group sessions or individual sessions for the day), or can be a permanent decision based upon the client or guardian.

Confidentiality

  1. All personal matters or personally-identifiable information discussed with the client in group or individual sessions are to remain confidential between the client and consultant. There are specific exceptions in which a breach of confidentiality may transpire:
    1. Written permission from the client and guardian
    2. There is a suspicion of abuse or neglect to be transpiring within any vulnerable population (child, elderly, individuals with a disability)
    3. The client is of imminent danger to themselves
    4. The client is of imminent threat to others

As a mandated reporter, I am required by law to report any incidents involving child abuse or maltreatment. The Summary Guide of Mandated Reporters In New York State is provided in this document from https://ocfs.ny.gov/publications/Pub1159/OCFS-Pub1159.pdf. Please refer to the bottom left section of the first page in this summary to learn more information about specific information that I am required by law to mandate.

  1. Group sessions
    It is not guaranteed that any and all personal information that is shared within a group setting will not be shared by the other teammates outside of sessions. Although it will be highly requested by the Mental Performance Consultant before each session to not share other individual’s information and that whatever information is shared within the group should stay within the group, the individual can remove themselves from a group session at any time they feel comfortable doing so, as well as determine for themselves what information they feel comfortable sharing in front of others. If an individual is more comfortable to share such information later in an individual session with only the Mental Performance Consultant, they are free to do so.
     

Session Fees

  1. Payment for all mental performance sessions is due prior to the session at the time of booking. Payments are processed securely through Square, and can be made using a credit or debit card.
  2. The consultant will discuss, if not already reviewed, the available session package options as well as individual session rates prior to your first session or at your request. Please ensure you understand and agree to the selected rate before proceeding with booking.
  3. Failure to provide payment prior to a scheduled session may result in the session being rescheduled or canceled.

Use of Technology

A. For educational and marketing purposes, portions of group session activities or materials may be recorded and shared on professional social media platforms (e.g., @mindyourperformancempc). These posts will never disclose personal or sensitive information.

C. Communication regarding session content or scheduling may take place via email at camryn@mindyourperformance.net. In addition, you may be provided with my phone number to be used exclusively for session-related matters. All communication will remain appropriate and within professional boundaries.

By signing below, I acknowledge that I have read and understood the information provided to me in this document regarding the services that will be provided to me, the confidentiality procedure within this line of work, session fees, and use of technology.

Clear Signature
MM slash DD slash YYYY

Step 1 of 4

MM slash DD slash YYYY
Examples: entrepreneur, working professional, performer, student, fitness enthusiast, creative, etc.